Provider Demographics
NPI:1770683419
Name:WILSON, MICHELLE LEE (DENTAL HYGIENIST)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:LEE
Last Name:WILSON
Suffix:
Gender:F
Credentials:DENTAL HYGIENIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 FARM MARKET ROAD 300
Mailing Address - Street 2:
Mailing Address - City:LEVELLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79336-6235
Mailing Address - Country:US
Mailing Address - Phone:806-987-1987
Mailing Address - Fax:806-894-3378
Practice Address - Street 1:1005 NORTH 16TH STREET
Practice Address - Street 2:
Practice Address - City:LAMESA
Practice Address - State:TX
Practice Address - Zip Code:79331-3151
Practice Address - Country:US
Practice Address - Phone:806-872-6310
Practice Address - Fax:806-872-6319
Is Sole Proprietor?:No
Enumeration Date:2006-09-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8101124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist